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“Give me 10 young people and I will shake the
world” is among founding president Sukarno’s famous quotes.

As we celebrate this nation’s 71st year of
independence, we should reflect on multifaceted challenges of human
development, from health and well-being perspectives.

Today, we can measure how the world views
human development by looking at the Sustainable Development Goals (SDGs).
Compared to its predecessor, the Millennium Development Goals (MDGs), the SDGs
leap not only in sophistication in crafting the interlinkages between goals but
also within each goal.

Take health as an example: its reach is not
limited to the health goal itself but also to at least four other goals:
poverty, food, gender and water and sanitation.

At the national level, challenges revolving
around human development are more complex than ever. Indonesia is the
fourth-most populated country in the world, with roughly 254 million people and
more than 17,000 islands.

It is clear that distribution of goods and
services is almost impossible to be done equally.

Even after 71 years of independence, challenges
in provision of health care remain mostly unchanged. Lack of transportation,
infrastructure, energy and isolation are the most common barriers to health
sector development and services in villages, especially those on the borders —
at Indonesia’s gateways.

In densely populated cities and semi-urban
dwellings, perhaps there is more access. However, quality and affordability
presents quite a substantial issue. Solving the challenges requires the
government to set its sight not only within the health sector, but
innovatively, also in sectors beyond health.

Compared to other developing countries,
Indonesia has not fully met the standards of people’s well-being. About a
quarter of the population is still left behind, compared to the 19 percent
across Asia, a global report found. This is mostly caused by the widening
inequality throughout the country.

Goods and services are not equally
distributed between urban and rural areas due to poor transportation,
insufficient infrastructure and information illiteracy.

As the first responders to community health
and well-being, primary healthcare bears an enormous responsibility for solving
health issues in parallel with maintaining and increasing health status of the
community. In the new era, universal health coverage under the national health
insurance (JKN) program has to be readily available for all, regardless of
geography.

Be it in the mountains of Papua or in the big
cities like Jakarta, Surabaya and Medan; primary healthcare is called to
transform itself into an affordable, high-quality service.

For this transformation to happen, it calls
for commitment from the government to side with the people and at the same
time, to build public awareness on maintaining healthy lifestyles.

Against this backdrop of challenges and
complexities, in May 2015 the Health Ministry launched the Nusantara Sehat
(Healthy Archipelago) campaign, which deploys teams of health workers to
peripheral areas in Indonesia that desperately need a nudge to transform not
only their primary healthcare services but also their overall well-being.

Entering its fourth batch and making way to
its 250th team by end of 2016, Nusantara Sehat has proven there is still hope
in improving the country’s well-being through quality primary healthcare
services.

Since the program was launched, 855 youth;
early-career health professionals are on site, ensuring well-being is shared
equally between roughly 2.5 million people.

These young people are not just health
professionals but they are agents of change. Through its actions and
innovations, Nusantara Sehat has showcased how health sector development can be
an effective entry point to implementing sustainable development principles at
the local level.

Despite the challenges, in hard to reach places
such as the borders of Long Pahangai in West Kalimantan, Boven Digoel in Papua
and Belu in East Nusa Tenggara, its innovations in community empowerment
programs have helped reduce open defecation and child malnutrition, and helped
build reproductive health awareness among teenagers.

Its presence in each of the communities
embodies the optimistic spirit of independence and the visionary objective of
the SDGs.

Such initiative shows that the youth are in a
strategic position to push for transformation, beyond claiming demographic
dividend. The key is empowering them to start taking action, engaging
themselves in various fronts of development: health, education, energy, economy
and others.

This way, the transformation is beyond
sectoral: it is about transforming citizenship — from passive recipients of
government services to concerned and engaged citizens.

Rayssa A.
Putri, a student at Global Jaya School, Bintaro, South Tangerang, Banten, is a
student volunteer with Nusantara Sehat campaign. Diah S. Saminarsih is special
adviser to the health minister on partnerships and Sustainable Development
Goals(SDGs), and founder of the Center of Indonesia Strategic Development
Initiatives (CISDI).

The condition of the country’s healthcare
system couldn’t be more ironic. While it is dubbed as one of the potentially
biggest markets in the world, Indonesia seems incapable of giving patients more
than the most basic of care.

Barely having recovered from a nationwide
fake vaccine scandal that affected more than a million children, a recent study
by the University of Indonesia (UI) has uncovered potential fraud in the
National Health Insurance (JKN) scheme’s hospital claims costing as much as Rp
7 trillion (US$526.7 million).

These incidents further call into question
the government’s capacity to manage the healthcare scheme, which already covers
170 million individuals, one of the largest in the world. Hospitals and health
facilities, which are still far from adequate in quantity, are still weak at
delivery points and with little scrutiny from the government.

Although the meager care is a logical
consequence of the scant system, it is hardly tolerable. The government should
prioritize the expansion of healthcare provision as more people register for
national insurance. The persistent lack of health infrastructure facilities, as
a result of the domestic failure to keep up with growing demand for care,
should no longer be accepted as an excuse.

The ideal is to have the government build the
health infrastructure by establishing health centers in remote areas that are
less attractive for the private sector. But as the government is grappling with
financing its more than $400 billion worth of infrastructure projects, it may
consider opening up the domestic healthcare sector to foreign investors and
providers to accelerate expansion.

Indonesia has been seen as a promising market
exactly because of the largely underdeveloped health system. It is among the 15
fastest growing markets globally, according to Oxford Business Group, which
estimated that the country’s healthcare sector will be worth $50 billion by
2020.

In the earlier years of the JKN, rolled out
by the Health and Social Security Agency (BPJS Kesehatan), it has already
driven sales of medical devices, such as MRI machines, PET-CT scanners, most of
which are imported. The market is still lucrative despite complicated import
mechanisms.

The presence of foreign operators may
increase the availability of services and spur competition in the sector. The
problem of opening the domestic healthcare market to foreign investors, however,
is more than just cutting red tape and rolling out the red carpet to investors.

The government should also improve monitoring
of healthcare providers, especially hospitals and other medical centers in
which malpractice frequently occurs and in which the fake vaccines were found.

Without a strong regulatory framework and
effective monitoring system, the opening of the domestic healthcare market will
only lead to further abuse of patients.

The UI study found that among the irregular
claims from hospitals were an abnormally high number of babies delivered via
C-section under the JKN, about 54 percent of 1.5 million babies delivered from
January 2014 to July 2015. The unusually high prevalence of this procedure,
which normally should be less than 10 percent of total child births, increased
substantially the sums that had to be paid out by BPJS Kesehatan.

Even if more foreign providers are present, a
lack of monitoring of the quality of drugs and treatments will prevent
improvement in the quality of service, while costs will rise as a result of
imported drugs and treatments. And how much will people have to pay for the
government’s basic insurance if costs spiral out of control?

The government should encourage investors and
providers that can accept the modest market that characterizes the country.
These investors should have an interest in producing generic drugs and have the
capability to expand services for lower- and middle-income patients under the
JKN.

More also should be done to improve the JKN’s
tariff system. With evidence of mismanagement, the BPJS Kesehatan should not
rely on a reimbursement system to hospitals to support the health scheme. The
agency should instead limit drugs and types of treatments that can be provided
by hospitals and health centers under the insurance scheme. It can also start
to directly procure drugs from pharmaceutical companies, rather than only
accepting bills from hospitals.

Bargaining directly with pharmaceutical
companies and other providers is a common practice in more advanced national
insurance schemes in other countries.

In France, doctors and other health
professionals in private practice are paid directly by patients. Health centers
are still reimbursed by fees and charges set nationwide, while state hospitals
receive annual operating budgets. In the UK, the National Health Service (NHS)
directly carries out its own drug procurement.

These two pioneers in national health
insurance schemes are not without criticism. Both are currently experiencing
deficits amid an economic slowdown and ageing populations in the region.

The biggest disappointment is finding that
the JKN is failing before it even gets around to extending healthcare to all of
the country’s population. It is like firing up the gas in the burner but the
hot air balloon still never being able to get off the ground.